Enucleation of Pancreatic Endocrine Tumor Following Pancreatic Duct Stenting

Sun Choon Song,Min Jung Kim,Woo Seok Kim,Dong Wook Choi,Jin Seok Heo,Seong Ho Choi 한국간담췌외과학회 2010 한국간담췌외과학회지 Vol.14 No.4

Pancreatic fistula is the most frequent complication after pancreatic resection regardless of the extent of the resection. A 68-year-old woman with B-viral hepatitis was referred with an incidentally detected pancreatic head mass that was diagnosed 4 months previously when performing following up of her liver cirrhosis. She had no specific symptoms, but she had a 1.2 cm sized solitary mass that was suspected to be a pancreatic endocrine tumor and it was located very close to the main pancreatic duct in the pancreas uncinate process on the imaging workup. Preoperative endoscopic pancreatic stenting was prepared to guide the enucleation of the mass while identifying the pancreatic duct using intraoperative ultrasonography. Precise intraoperative estimation of the mass and the pancreatic duct was possible and the enucleation was successful without injury to the duct. We recommend this operative approach especially when planning local pancreatic resection for tumors in the pancreatic head or uncinate process, as these tumors make the pancreatic duct vulnerable to injury.

췌관-공장 문합술에서 흡인형 췌관 스텐트의 초기 결과 보고

안영준(Young Joon Ahn),황기태(Ki-Tae Hwang),허승철(Seung-Chul Heo),정인목(In Mok Jung),정중기(Jung Kee Chung),장진영(Jin-Young Jang),김선회(Sun-Whe Kim) 대한외과학회 2007 Annals of Surgical Treatment and Research(ASRT) Vol.72 No.6

Purpose: We wanted to evaluate the feasibility of using the suction pancreatic duct stent, which was designed to aspirate pancreatic fluid more actively around the pancreaticojejnostomy site during performance of pancreaticoduodenectomy for preventing pancreatic fistula. Methods: In 7 consecutive pancreaticoduodenectomy patients, we inserted a PVC tube into the remnant pancreatic duct across the duct-to-mucosa type pancreaticojejunostomy at a 2 ㎝ depth as a totally external pancreatic stent. This stent was connected with the aspiration bag of a Jackson-Pratt drain for generating negative pressure. We inserted another Jackson-Pratt drain beneath the pancreaticojejunosomy site and checked the amylase level in the body fluid and the serum at the postoperative 1st and 5th days for evaluating pancreatic leakage. We also checked the daily amount of pancreatic fluid obtained through the suction stent. Pancreatic fistula was defined as an amylase level in the body fluid >10,000 U/L on postoperative 1 day or an amylase level in the body fluid >3 times the serum amylase level on the postoperative 5th day. Results: On postoperative day 1, the mean level of intraabdominal fluid amylase was 1,404 U/L (355∼3,850 U/L). On the postoperative 5th day, the mean level of amylase in the body fluid was 40.3 U/L (12∼144 U/L) and the mean level of serum amylase was 38.3 U/L (19∼71 U/L). Even on the postoperative 1st day, we could collect a considerable amount of pancreatic fluid (mean: 55.6 ㎖ (range: 9∼169 ㎖)). There was no complication associated with pancreatic leakage. Conclusion: The suction pancreatic stent can be a feasible method to prevent pancreatic leakage. Additional randomized studies to compare the conventional pancreatic duct stent with the suction pancreatic duct stent are mandatory.

췌관을 결찰한 닭 췌장 외분비부의 형태학적 변화

구세광,이재현,이형식,Ku, Sae-kwang,Lee, Jae-hyun,Lee, Hyeung-sik 대한수의학회 1997 大韓獸醫學會誌 Vol.37 No.2

To investigate morphological changes in the exocrine pancreas of chicken after pancreatic duct ligation, experimental animals were subdivided to control, 12 hours, 1 day, 2 days, 4 days, 7 days and 10 days groupes and all of three pancreatic ducts of chicken were ligated by surgical procedure and then the morphological changes were observed. In pancreatic ducts, once for a while the ducts were dilated on 12 hours after pancreatic duct ligation and then they were obstructed because of proliferated epithelial cells and connective tissues in pancreatic duct. Marginal dissociation of acini was detected in 12 hours after pancreatic duct ligation and then dissociation of acini was increased with time and finally in 4 days after pancreatic duct ligation the acini showed completely dissociation except periductular regions and around pancreatic islets. Most of dissociated acini cells showed marginal condensation of nuclear chromatin and atropy of cytoplasm, namely, apoptotic features were detected in dissociated acinar cells. Interacinar spaces of dissociated acinar regions were dilated and fulfilled with increased connective tissue and in 4 days after pancreatic duct ligation, deposition of lymphocytes and hemocytes was occurred.

Management of intractable pancreatic leak from iatrogenic pancreatic duct injury following resection of choledochal cyst in an adult patient

Jin Uk Choi,Shin Hwang,Yong-Kyu Chung 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.2

Iatrogenic pancreatic duct injury can occur during resection of the choledochal cyst (CC). We herein present a case of postoperative pancreatic fistula (POPF) developed after resection of the CC in an adult patient with variant anomalous union of pancreatobiliary duct. The 55-year-old female patient underwent surgery after the diagnosis of CC-associated gallbladder cancer. During surgery, the CC mass was accidentally pulled out, by which the intrapancreatic CC portion was torn out from the main pancreatic duct. Since the pancreatic duct stump was not identified due to its small size, repair was not possible. The excavated defect at the pancreas head was closed securely combined with insertion of multiple drains. Postoperative POPF and peripancreatic fluid collection developed and the patient had to be fasted for 4 weeks. She was first discharged at 6 weeks after surgery. At 10 weeks, she was readmitted due to progression of peripancreatic fluid collection, which was controlled by percutaneous drain insertion. At 6 months, she was readmitted again due to repeated progression of peripancreatic fluid collection, which were controlled by endoscopic transmural duodenocystostomy. It took 8 months to resolve the pancreatic duct injury-associated pancreatitis. The experience in this case suggests that iatrogenic pancreatic duct injury during resection of CC can induce catastrophic complications, thus special attention should be paid to prevent pancreatic duct injury.

Intrahepatic Bile Duct Dilatation Caused by Pancreatic Pseudocyst: A Case Report

Donghyeon Kim,박미현 대한자기공명의과학회 2022 Investigative Magnetic Resonance Imaging Vol.26 No.4

Pancreatic pseudocyst can fistulize to adjacent organs such as stomach, duodenum, colon, and esophagus. Fistula formation with bile duct is rare. Reported cases of biliary involvement of pancreatic pseudocyst include fistula formation between the pancreatic pseudocyst and common bile duct. Intrahepatic bile duct dilatation caused by fistula formation with pancreatic pseudocyst is extremely rare. There are no published reports to the best of our knowledge. Herein, we report a case of intrahepatic bile duct dilatation caused by fistulous communication with a pancreatic pseudocyst. The peripheral intrahepatic bile duct surrounding the pseudocyst was dilated without involving the common bile duct. Magnetic resonance cholangiopancreatography image showed a connection between the pancreatic pseudocyst and dilated intrahepatic bile ducts with a multifocal cystic and beaded appearance.

Anterior pancreatic duct split prior to duct-to-mucosa pancreatico-jejunal anastomosis in pancreaticoduodenectomy

Srikanth Gadiyaram,Murugappan Nachiappan 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.3

A secure pancreatic-enteric anastomosis is widely accepted as the ‘Achilles heel’ in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the ‘duct-to-mucosa’ technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.

간장 ( 肝臟 ) · 담도 ( 膽道 ) 및 췌장 ( 膵臟 ) : 만성 췌장염에서의 췌관확장술

조성원(Sung Won Cho),심찬섭(Chan Sup Shim),김진홍(Jin Hong Kim),이문성(Moon Sung Lee),김홍수(Hong Su Kim),조영덕(Young Duk Cho) 대한소화기학회 1991 대한소화기학회지 Vol.23 No.4

N/A We report a case of chronic recurrent pancreatitis accompanied by multiple stenosis of the main pancreatic duct which successfully treated by endoscopic dilatation of pancreatic duct. Chronic pancreatitis with stenosis of pancreatic duct was diagnosed clinically and by endoscopic retrograde cholangiopancreatography. In order to relieve recurrent abdominal pain, we performed endoscopic pancreatic bougination with Soehenda biliary uilatation catheters and balloon dilatation with Rigiflex biliary balloon catheters. No significant complications occurred following pancreatic duct dilatation except mild pancreatitis associated with pancreatic manipulation. We conclude that endoscopic pancreatic duct dilatation as a method to treat chronic pancreatitis is encouraging, but large series and longer term follow-up are necessary before its efficacy can be determined.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology

Tanyaporn Chantarojanasiri,Hiroyuki Isayama,Yousuke Nakai,Saburo Matsubara,Natsuyo Yamamoto,Naminatsu Takahara,Suguru Mizuno,Tsuyoshi Hamada,Hirofumi Kogure,Kazuhiko Koike 거트앤리버 소화기연관학회협의회 2018 Gut and Liver Vol.12 No.2

Background/Aims: Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published. Methods: Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed. Results: There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP. Conclusions: Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.

Air in the main pancreatic duct: a case of innocent air.

Kim, Yun Ji,Kim, Hyung Keun,Cho, Young Seok,Kim, Sung Soo,Chae, Hiun Suk,Kim, Seung Kyong,Kim, Eun Sun,Lee, Su Yeon WJG Press 2012 WORLD JOURNAL OF GASTROENTEROLOGY Vol.18 No.36

<P>Air in the main pancreatic duct has been reported only rarely and might be associated with either a spontaneous or a surgically induced alteration of the anatomy of the biliary tract. We report a case of 'innocent' air found incidentally in the main pancreatic duct. To our knowledge, this is only the third such case reported. A 54-year-old woman presented with hemoptysis that had lasted for 3 d. She underwent a chest computed tomography scan, which revealed not only focal bronchiectasis in the left lower lobe, but also air in the main pancreatic duct and dilatation of the common bile duct. She was managed conservatively for the hemoptysis and no further problems developed. She had no specific gastrointestinal symptoms and had no history of surgery or medication. Her laboratory parameters were normal. Magnetic resonance cholangiopancreatography also demonstrated air in the main pancreatic duct and a dilated common bile duct (CBD). Duodenoscopy revealed separate biliary and pancreatic orifices with patulous openings and some air bubbles appearing in the pancreatic orifice. Endoscopic retrograde cholangiopancreatography (ERCP) showed the dilated CBD and pancreatic duct with some air bubbles, but no other abnormal lesions. She was discharged with no further problems. Most patients with air in the main pancreatic duct have had a pancreatobiliary disease, or a history of pancreatobiliary disease, pancreatobiliary surgery or sphincterotomy. If the air is innocent, as in our case, ERCP should be performed to evaluate any altered sphincteric function or anatomy such as patulous openings.</P>

증례 : 소화기 ; 작은 크기에서 현저한 주췌관 확장과 췌장실질 위축을 동반한 신경내분비종

원성현 ( Sung Hyun Won ),홍승모 ( Seung Mo Hong ),김명환 ( Myung Hwan Kim ),박상우 ( Sang Woo Park ),최윤식 ( Yun Sik Choi ),장일영 ( Il Young Jang ),김형중 ( Hyoung Jung Kim ) 대한내과학회 2014 대한내과학회지 Vol.86 No.5

췌장 신경내분비종양은 작은 크기에서도 췌관의 협착에 의한 상류쪽 주췌관의 확장을 동반할 수 있다. 췌관을 직접 침범하지 않고도 췌관의 협착이 발생할 수 있으며 특징적으로 세로토닌 면역염색에서 양성을 보이는 경우가 많다. CT에서 조영증강되는 종괴가 있으면서 주췌관의 확장과 췌장 실질의 위축이 동반될 경우, 일단 췌장선암의 존재 여부를 확인하는 것이 가장 중요하지만 췌장 신경내분비종양도 감별진단에 포함해야 한다. 그리고 세로토닌 분비 췌장 신경내분비종양 가능성을 고려하여 추가 면역화학염색이 필요함을 생각할 수 있다. Pancreatic ductal adenocarcinomas often cause marked pancreatic duct dilatation and associated parenchymal atrophy. We present the case of a small pancreatic neuroendocrine tumor with upstream pancreatic duct dilatation and severe parenchymal atrophy. A small enhancing tumor was observed at the head of the pancreas on computed tomography (CT). Endoscopic ultrasonographyguided fine-needle aspiration was negative for malignancy. We performed a pylorus-preserving pancreatoduodenectomy since we could not exclude the presence of pancreatic ductal adenocarcinoma. The pathological and immunohistochemical examination revealed a serotonin-positive neuroendocrine tumor, measured 1.0 × 0.5 cm. The pathological specimen was remarkable for the marked stromal fibrosis in the area of the tumor, which resulted in narrowing of the main pancreatic duct. Here, we report a rare small pancreatic neuroendocrine tumor, the CT image of which resembled that of pancreatic ductal adenocarcinoma, in which the expression of serotonin and associated fibrosis might be a possible mechanism for the marked main pancreatic duct dilatation. (Korean J Med 2014;86:598-602)